Submission to Department of Health and Ageing regarding the Commonwealth Home and Community Care (HACC) Program

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1 Dietitians Association of Australia Submission to Department of Health and Ageing regarding the Commonwealth Home and Community Care (HACC) Program April 2013 Contact Person: Annette Byron Position: Senior Policy Officer Organisation: Dietitians Association of Australia Address: 1/8 Phipps Close, Deakin ACT 2600 Telephone: Facsimile:

2 Contents Recommendations... 3 DAA interest in the HACC program... 4 HACC Program Manual Specialist referral for nutritional advice... 5 HACC Program Manual Role of dietitians in HACC Programs... 5 HACC Program Manual Centre-based day care... 6 HACC Program Manual Meals... 6 Lack of current food and nutrition guidelines... 6 Training of community workers... 7 Community Common Care Standards (CCCS)... 7 Policy on service delivery... 7 Indicators used to measure service delivery... 8 References... 8 Appendix 1 Qualifications of dietitians and nutritionists

3 Recommendations DAA would welcome the opportunity to work with the Australian Government Department of Health and Ageing to improve the nutritional wellbeing of older Australians through the HACC program and recommends the following actions. 1. Amend the HACC Manual and advise HACC service providers that Accredited Practising Dietitian is the specialist service for referral regarding nutrition advice. 2. Recognise the role of dietitians in HACC programs more comprehensively and consistently to include individual care and systems based support. 3. Recognise the role of centre based day care in improving nutritional risk through provision of meals and nutrition risk screening. 4. Develop national nutrition guidelines for Meals on Wheels (MOW) and centre based day care. 5. Develop and implement a quality monitoring and surveillance program to ensure nutrition initiatives improve nutrition outcomes for HACC clients. 6. Include nutrition in the training of staff employed by service providers, with content relevant to their role. 7. Expand the Community Common Care Standards (CCCS) with respect to nutrition including nutrition risk screening, referral for at risk clients to dietitians and nutrition training for relevant HACC staff. Develop additional materials and training for auditors of aged care agencies to support these changes. 8. Develop and fund consistent nutrition service delivery models nationally under HACC to support individual and systems based care. 9. Develop and implement appropriate measures of service delivery to reflect individual and systems based care as outlined in The Health Activity Hierarchy Version

4 DAA interest in the HACC program The Dietitians Association of Australia (DAA) acknowledges the valuable work done for many years under the HACC program to support older Australians. However, the safety and quality of nutrition related services could be improved to promote nutritional well being of HACC Program recipients in accordance with two guiding principles of the Program 1 Promote each client s opportunity to maximise their capacity and quality of life Provide appropriate workforce training and development. Full funding and program responsibility under the Australian Government from 1 July 2012 for basic maintenance, support and care services for older people previously delivered through the Commonwealth HACC Program (HACC) in all states and territories, except Victoria and Western Australia, presents opportunities to address issues of concern regarding nutrition. DAA is concerned about the nutritional wellbeing of older Australians living in the community or in residential care and makes the following points Access to food is a basic human right 2. Good nutrition is an essential part of preventing and managing chronic disease, maintaining independence and supporting quality of life in older people. Anecdotally HACC dietitians report malnutrition in older Australians with multidimensional contributing factors, consistent with published reports 3. An inability to meet nutritional needs is often a contributing factor in older people entering residential aged care 4,5. Robust nursing, food service and other systems are needed to prevent malnutrition. They also provide a platform for effective individual case management by APDs. DAA also has an interest in the HACC program arising from the role of Accredited Practising Dietitians (APDs) who provide dietetic services under the program. APDs have unique skills, qualifications and experience in medical nutrition therapy for individual case management, community and public health nutrition, and food service management. 4

5 HACC Program Manual Specialist referral for nutritional advice (3.2.3 Service Group Three - Allied health care) The Manual suggests that the specialist service to refer to for nutritional advice is a dietician or nutritionist. The Manual also states that Allied health care must be provided by appropriately qualified professionals. Service providers must ensure that the practitioners they use comply with relevant Commonwealth, state and territory legislation. For nutrition services, this is an Accredited Practising Dietitian (APD), and not a nutritionist. The APD credential is the platform for self regulation of the dietetic profession 6 in the absence of registration under the Australian Health Practitioner Regulation Agency. The credential is accepted by Medicare, the Department of Veterans Affairs, and most private health funds. A recent Administrative Decision from the Australian Government Department of Health and Ageing requires the APD credential for access to the Healthcare Identifiers Service to access and upload to client electronic health records. Additional information about the qualifications of dietitians and nutritionists is provided in Appendix 1. It should be noted that the accepted spelling of dietitian is with a t. HACC Program Manual Role of dietitians in HACC Programs (3.2.3 Service Group Three - Allied health care) The Manual states Allied health care may be delivered in a client s home, to an individual at a day centre, or in a group environment. DAA considers that this description does not adequately cover the scope of what HACC dietitians currently do, and that a more comprehensive description would be helpful to Manual users. For example, HACC dietitians assess nutritional status and implement a nutrition care plan for individual clients in the home, centre based care or clinic setting assist HACC service providers to incorporate nutrition risk screening into their assessment processes advise meal service providers in day care centres or MOW to support delivery of quality nutrition and food educate care workers and food service workers advocate for good nutrition for clients over the age of 65 to carers, policy makers and the wider community via events, programs, health promotion activities, conferences and meetings. 5

6 HACC Program Manual Centre-based day care (3.2.4 Service Group Four Centre-based day care) Day centres play an important role in assisting HACC clients to continue living in the community by providing opportunities for social interaction. Centre-based day care may also support nutrition needs by providing meals. In fact studies have shown that community meal programs can improve or maintain nutritional risk for vulnerable seniors 7-9. DAA is concerned that the HACC Manual does not identify the provision of nutritionally adequate meals or nutrition risk screening as important functions of Day Centres. HACC Program Manual Meals (3.2.6 Service Group Six - Meals) The Manual states Paid staff and volunteers involved in the preparation and handling of food should be provided with information regarding safe food handling as it relates to their activities. DAA is concerned that no mention is made of meals meeting the nutrition needs of the client group. HACC providers are well positioned to identify nutrition issues and risks in community living older people and to contribute to the prevention and treatment of these issues. Lack of current food and nutrition guidelines DAA understands that there are various guidelines for food services which are used by MOW depending on the jurisdiction, published as early as and as late as Also, that state HACC program manuals do not all make recommendations as to the nutritional quality of MOW and/or centre-based day care meals. APDs report however that even when there are guidelines in existence, these are not always followed. APDs have identified varying skills and knowledge of nutrition in HACC services, and a lack of monitoring of the process of preparing suitable meals. DAA is concerned that there are no current national guidelines for food and nutrition services in centre-based day care or MOW. There is also concern about the lack of quality monitoring and surveillance for the implementation of such guidelines. 6

7 Training of community workers DAA is concerned that the current training of care workers or food service workers, such as cooks or chefs, does not adequately prepare workers for residential care or community care with respect to the general nutrition needs of HACC clients, or special diets. DAA is also aware that Certificates III and IV 12,13 in Aged Care contain very little content on nutrition related issues, despite the importance of the qualifications in the HACC and aged care sector Consequently, DAA welcomes the initiative to review Home and Community Care (HACC) and Allied Health Assistance training packages. DAA has nominated representatives to the two Subject Matter Expert Reference groups which have been convened to contribute to this revision. Community Common Care Standards (CCCS) DAA understands that the CCCS Guide 14 has been developed to assist service providers to prepare and participate in a quality review, and for use by quality reviewers in conducting quality reviews of community care services. The tool used to audit HACC services could be used to promote better nutritional care. Although nutrition is addressed under Independence, there is little reference to the provision of nutritional meals by HACC services or to nutrition risk screening. Consequently auditing is not likely to pick up the varying quality of meals provided in centre based day care and MOW, or clients who are at nutritional risk. DAA would like to see a greater emphasis on nutrition in the audit tool, in a manner similar to the section of Nutrition in the latest EQuIP Hospital Accreditation Standards 15, or the Nutrition Standard developed in Victoria as an 11 th Clinical Indicator under the Australian Safety and Quality Commission 16. Policy on service delivery Practitioners report considerable variation in approaches to service delivery, for example each HACC dietetic service in New South Wales has its own service delivery model depending on service structure and funding. Some programs provide clinical services only due to limited funding. Tasmania does not have funding for the clinical care that other states include in their service delivery models. DAA considers that effective service delivery requires resourcing for dietetic services to support community care and food service systems, and individual case management of 7

8 medical nutrition therapy. Resourcing of services should be nationally consistent and meet community needs. Indicators used to measure service delivery DAA understands that where medical nutrition therapy i.e. clinical services are delivered, there are specific outputs which are expressed as hours per year. One-to-one client hours, phone calls, and care coordination are included, but travel time, group education and training are excluded although this may vary depending on the jurisdiction. APDs in New South Wales report that there was initial training in the HACC Minimum Data Set (MDS) Version but no ongoing training, and virtually no training for new employees. Discrepancies have been identified between the data entered by clinicians compared to reported data, for example Southwest Sydney dietitian inputs in November- December 2012 were 117 hours, but the Department of Health and Ageing reported outputs were 42 hours. DAA contends that management of services requires appropriate measurement of service activity, training in the recording of service activity and information technology for data collection. Measurement should cover the elements of service provision including clinical care, clinical services management, teaching and training, and research as outlined in The Health Activity Hierarchy Version References 1. Australian Government Department of Health and Ageing. Commonwealth HACC Program. Commonwealth of Australia Available from 2. Rome Declaration (1996) United Nations Food and Agriculture Organisation. Available from < Accessed 8 March Rist G, Miles G, Karimi L. The presence of malnutrition in community-living older adults receiving home nursing services. Nutr Diet 2012; 69: Charlton K. Nutrition screening: Time to address the skeletons in the bedroom closet as well as those in hospitals. Nutr Diet 2010; 67:

9 5. Kendig H, Browning C, Pedlow R, Wells Y and Thomas S. Health, social and lifestyle factors in entry to residential aged care: an Australian longitudinal analysis. Age and Ageing 2010; 39: APD Program. Dietitians Association of Australia. Available from 7. Brooks D. Vitalising Links. Southern Sydney Centre Based Day Care Project Report. Southern Community Care Development Kewller H. Meal programs improve nutritional risk: A longitudinal analysis of community living seniors. J Am Diet Assoc 2006; 106: Millen BE, Ohls JC, Ponza M and McCool. The elderly nutrition program: An effective national framework for preventative nutrition interventions. J Am Diet Assoc 2002; 102: Meals on Wheels Association of Tasmania Inc and Red Cross Delivered Meal Services Tasmania. Standards and code of practice for delivered meals Tasmania Queensland Meals on Wheels Nutrition Manual Available from Certificate III in Aged Care. Available from Certificate IV in Aged Care. Available from Australian Government Department of Health and Ageing. Community Care Standards Guide EQuIP. Australian Council on Health Care Standards. Available from Draft Victorian Nutrition Standards and Guide for use in hospitals Available from Nutrition-Standard-and-Guide-for-use-in-hospitals---Draft 17. Australian Government Department of Health and Ageing. Home and Community Care Program. National Minimum Data Set User Guide. Version Available from National Allied Health Casemix Committee. The Health Activity Hierarchy Version 1.1. Melbourne Available from 9

10 Appendix 1 Qualifications of dietitians and nutritionists Dietitians Dietitians graduate from four year undergraduate or two year postgraduate courses at Australian universities accredited by DAA. These courses have a strong human nutrition science base, and are delivered in an evidence-based paradigm. Dietitians must demonstrate skills and knowledge in a comprehensive set of competencies in three dominant areas of practice: individual case management, community and public health nutrition and food service management. Overseas trained dietitians must have their qualifications recognised in a process conducted by DAA for the Australian Government Department of Industry, Innovation, Science, Research and Tertiary Education. Nutritionists Some nutritionists have three or four year degrees in human nutrition science. DAA knows from its experience in assessing applications for associate membership of DAA that the course content taken by nutrition graduates from Australian universities varies widely. DAA considers that nutritionists with human nutrition science of similar depth and breadth to that studied by dietitians, may work in areas such as academic positions, research, and the food industry. However, they invariably lack the theory and practical application of counselling around nutrition and disease; and they do not have supervised professional practice in individual case management or food service. It is for these reasons that DAA considers that dietitians are nutritionists, but nutritionists cannot be dietitians. This holds true in Australia, but may not be so in other countries. Furthermore, some nutritionists study nutrition within a natural therapy course, offered at diploma, degree or lesser level for varying lengths of time at an Australian university or other Higher Education Provider. DAA considers that such courses are taught from a natural therapy paradigm, rather than an evidence based paradigm. There would be an unacceptable level of risk in terms of safety and quality if graduates of these courses provided services to clients in HACC programs. 10

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